Norman Regional Hospital Board of Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting January 23, 2023 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, January 23, 2023 at 5:30p.m. in the Conference Room at Norman Regional Nine. The meeting Agenda was posted January 19, 2023 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley Joan Greenleaf Dianne Chambers, MD Muhammad Anwar, MD Mary Womack James Chappel Paula Roberts Others Present: Richie Splitt, President & CEO John Manfredo, Chief Operations Officer Brittni McGill, Chief Nursing Officer Ken Hopkins, Chief Financial Officer Keith Minnis, VP Chief People Officer Elaine Purvis, VP Chief Strategy Officer Aaron Boyd, MD, Chief Medical Officer Joe Voto, MD, Chief of Medical Staff James Bond, MD, Chief of Medical Staff Elect Jenny Anderson, Administrative Director, Patient Quality Shannon Largent, Administrative Director, Patient Care Services & Accreditation Kara Cornell, Administrative Fellow Jack DeLester, OU’s JC Penny Leadership Fellow Maggie Martin, Attorney, Crowe & Dunlevy Melissa Herron, Director, Integrated Marketing Ray Leyva, Multimedia and Video Specialist Annette Troxell, Director Patient Care Services Clyde Brawner, Director Environmental Services, Distribution & Transportation Tracy Mills, Nurse Manager Amy Hawley, Supervising Nurse Willa Pendley-Griffin, RN Eric Wierenga, Guest Louis Porter, Environmental Service Technician II Member Absent: Jerome (Jerry) Weber, Ph.D. Kevin Pipes  NRHA Board Minutes 2 November 28, 2022 Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called to order the January 23, 2023, Norman Regional Hospital Authority business meeting at 5:32p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. January 2023 Healer of the Month – Louis Porter, Environmental Services Technician II. Mr. Cubberley introduced Mr. Clyde Brawner, Director, Environmental Services & Distribution/Transportation. Mr. Brawner shared Mr. Porter has been a Floor Tech with NRHS for just over 2 ½ years. Mr. Porter is very flexible and is a healer, who is capable of performing a multitude of tasks. Mr. Porter has an extensive and varied background. He previously worked as a bakery manager for 27 years and spent 20 years working with explosives and large machinery in the oil fields. His fellow healers share that he will help anyone at any time, never backing away from any issue. He is willing to float between campuses as needed and does so without complaining. Mr. Porter thanked his fellow healers for their support and honoring him with the nomination. Mr. Cubberley congratulated and thanked Mr. Porter on behalf of the Board for his outstanding dedication, professionalism, compassion and positive attitude that continues to make Norman Regional Health System a caring, high quality system. B. February 2023 Healer of the Month – Willa Pendley-Griffin, Registered Nurse II Mr. Cubberley introduced Ms. Tracy Mills, RN, Nurse Manager. Ms. Mills shared Ms. Pendley-Griffin became a healer at Norman Regional in July of 2020. During the pandemic, she jumped right in and assisted wherever needed. Her fellow healers note she is a great patient advocate, providing consistently reliable bedside reports for physicians. She always has a positive attitude and communicates this through her voice, attitude, smile and actions. Her fellow healers remarked she is always willing to lend a hand, asking where she is needed the most at that time.  NRHA Board Minutes 3 November 28, 2022 Ms. Pendley-Griffin thanked her fellow healers for their support and honoring her with the nomination. Mr. Cubberley congratulated and thanked Ms. Pendley-Griffin on behalf of the Board for her outstanding dedication, professionalism, compassion and positive attitude that continues to make NRHS a caring, high quality system. Mr. Splitt re-introduced Ms. Elaine Purvis, VP & Chief Strategy Officer and introduced for the first time Mr. Keith Minnis, VP & Chief People Officer. Mr. Splitt re-introduced Maggie Martin, our new legal counsel from Crowe & Dunlevy. Mr. Brawner, Mr. Porter, Ms. Troxell, Ms. Mills, Ms. Pendley-Griffin, Ms. Hawley and Mr. Wierenga left the meeting at 5:38pm. Mr. Leyva left the meeting at 5:45pm Agenda Item III. Board Education: High Reliability Organization Ms. Jenny Anderson, Administrative Director, Patient Quality and Shannon Largent, Administrative Director, Patient Care Services & Accreditation presented an overview of NRHS’s journey toward becoming a a High Reliability Organization. Attaining a HRO status is comparible to TS Eliot’s quote: The journey, not the destination matters…” Pursing HRO is the perpetual pursuit of perfection as an organization strives for failure free operations amid high levels of complexity. To be considered a High Reliability organization, you must create an environment of mindfulness; acknowledging that humans can make mistakes while working toward systems and processes that limit the likelihood of those mistakes. The foundation for a HRO includes four cornerstones:  Culture: Personal accountability, teamwork and collaboration, healthy environment and connections and alignment.  Leadership: Active, participating leaders coaching, providing positive feedback and empowering others while setting high expectations. The basic components of a learning system are: Learn & Design, Improve & Deploy and Implement & Sustain.  Knowledge: Seeing defects, problems or issues as an opportunity to improve.  Learning: Proactively seeking defects/failures vs. reactive action, resist temptation to jump to quick solutions, deploy Plan, Do, Study, Act (PDSA) and monitor quality of adherence to change. NRHS has several strategic plans already in place to achieve the HRO status:  Culture: Just, Culture, Crucial Conversations, ICARE and the Norman Way  Leadership: Luttrell Leadership Institute, Leadership Rounding, 360 and Gap Assessment  Knowledge: NEWs Wall and Safety Huddle  NRHA Board Minutes 4 November 28, 2022  Learning: PDSA At the February NRHA Board meeting, Ms. Anderson and Ms. Largent will provide an introduction to the HRO Metrics, processes and a Roadmap for NRHS. Ms. Largent left the meeting at 5:52pm. Agenda Item IV. Approval of November 28, 2022, Norman Regional Hospital Authority Board Meeting Minutes and the December 19, 2022 Norman Regional Hospital Authority Study Session A. Mr. Cubberley asked for approval of the November 28, 2022 Board Meeting Minutes ACTION TAKEN: Mr. Chappel made the motion to approve the November 28, 2022 Board Meeting Minutes. Ms. Greenleaf seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr Chambers, Dr. Anwar, Ms. Womack, Mr. Chappel and Ms. Roberts. B. Mr. Cubberley asked for approval of the December 19, 2022 Board Study Session Minutes ACTION TAKEN: Mr. Chappel made the motion to approve the December 19, 2022 Board Study Session Minutes. Ms. Greenleaf seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr Chambers, Dr. Anwar, Ms. Womack, Mr. Chappel and Ms. Roberts. Agenda Item V. Performance Update Ms. Jenny Anderson, Administrative Director, Patient Quality presented an update on the Journey to Excellence award. The Journey to Excellence Award represents a cycle of learning within the organization. The main goals of Process Improvement are:  Showcase Journey to Excellence Award applicants to a broader audience  Encourage award recipients to submit for regional/national awards and presentations  Align terminology and award excellence within the Baldridge Framework  Increase the number of applicants The purpose of the Journey to Excellence award is to recognize exceptional efforts of NRHS teams to improve processes within one or more of our four strategic focus areas: Services Excellence, Operational Excellence, Clinical Excellence and Team Excellence. This award represent the highest level of professional recognition within the health system and is awarded to projects that display a systematic approach to process  NRHA Board Minutes 5 November 28, 2022 improvement which is evidenced by a clearly defined problem statement and data driven results. Communications about the award and the application process is being announced across the health system. The oversight committee will schedule in-person project reviews in early April. Projects will be on display during hospital week, May 8-12 and all winners will be announced during the Management Team meeting on June 30 th. Agenda Item VI. Medical Staff A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on January 11, 2023. MEC covered a number of topics including – Transfusion Competency Policy, Stroke Committee Order sets and Reflex Urine Cultures, quarterly finance report, Medical Credentialing report and Department/Committee reports. Agenda Item VII. Patient Quality & Safety Committee A. Mr. Cubberley announced a summary of the Patient Quality & Safety Committee Meeting is included in the board packet. Ms. Greenleaf is available to address questions. Agenda Item VIII. Strategic Planning Committee A. Mr. Cubberley announced a summary of the Strategic Planning Committee Meeting is included in the board packet. Dr. Weber is available to address questions. Agenda Item IX. Finance Committee A. Mr. Hopkins reported the Finance Committee met January 16, 2023. B. Mr. Hopkins presented the NRHS Financial report for December 2022: December 2022 Financial Performance  Gross Revenues .................................. (Budget $237,031,021)............ $227,852,638  Net Patient Revenue .............................. (Budget $48,791,464).............. $49,724,827  Total Operating Expenses ..................... (Budget $48,842,347).............. $50,171,887  Total Operating Revenues ...................... (Budget $49,223,706).............. $50,188,867  Operating Income ....................................... (Budget $381,359)................... ($16,980)  Non-Operating Revenues (Expenses) ........ (Budget $774,345)................... ($99,307)  Excess Revenues over Expenses ............ (Budget $1,155,704)................... ($82,327) Year-to-Date  Operating Income ..................................... (Budget $1,419,250............ ($21,901,662)  NRHA Board Minutes 6 November 28, 2022  Non-Operating Revenues (Expenses) ..... (Budget $4,906,485)............... ($4004,214)  Excess Revenues over Expenses ............ (Budget $3,487,235)............ ($17,897,448)  Accounts Receivable Days ............................ (Budget 48 Days) .................. 45.2 Days  Days Cash on Hand…………………………………………………………….137.5 Days ACTION TAKEN: Ms. Greenleaf motioned to approve the December 2022 NRHS Financial Statements. Mr. Chappel seconded the motion. December 2022 Financials were approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Dr. Anwar, Ms. Womack, Mr. Chappel and Ms. Roberts. C. Mr. Hopkins presented for approval one capital request items totaling $152,756 a. Patient Monitoring System: $152,756 ACTION TAKEN: Ms. Greenleaf made a motion to approve the Capital Equipment Request at a total cost of $152,756 as recommended by the Finance Committee. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Dr. Anwar, Ms. Womack, Mr. Chappel and Ms. Roberts. Mr. Splitt announced Mr. Hopkins will leaving Norman Regional to pursue other interests. Mr. Splitt thanked Mr. Hopkins for his devotion to the health system and community. His tireless service and dedication to NRHS healers is truly appreciated. Agenda Item X. Old Business None. Agenda Item XI. New Business A. Review Date and Times for 2023 Schedule of Authority Meetings ACTION TAKEN: Mr. Chappel made a motion to approve the change of locations for the 2023 Authority Meetings. Mr. Anwar seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Dr. Anwar, Ms. Womack, Mr. Chappel and Ms. Roberts. Mr. Splitt announced the OU Health Stephenson Cancer Center transition for the Medical Oncology Department took effect today. This partnership between Norman Regional and the OU Stephenson Cancer Center provides only the 2nd location in the state of Oklahoma that is a National Cancer Institute designated Cancer Center. Mr. Splitt announced Mr. Manfredo and Ms. Purvis are now leading the Recovery & Transformation team. They will bring updates from the committee as they become available.  NRHA Board Minutes 7 November 28, 2022 Agenda Item XII. Administrative Report Mr. Splitt announced NRHS now qualifies for the federal 340B Drug Pricing Program. The 240B Drug Pricing Program allows qualifying hospitals and clinics that treat low-income and uninsured patients to buy outpatient prescription drugs at a discounted rate. Mr. Splitt provided an update on LifeCare. Ms. Meegan Carter in her new role as VP of Operations at LifeCare, is working to align the hospitals into a more clinically integrated network, focusing on value-based care while working to align with the state’s Managed Medicaid program. Mr. Splitt reported the OHA (Oklahoma Health Care Authority) will award 3 Managed Care contracts to Managed Care Organizations (MCO). Of the three contracts, at least one will be a Provider Led Entity (PLE). NRHS will be a participant in all MCO contracts as LifeCare will pursue an equity position in a PLE. Mr. Splitt reported the Oklahoma Hospital Association continues its work with state legislators to find opportunities to improve financial sustainability for hospitals across the state. Mr. Splitt announced Ms. Purvis and her team will begin focusing on the next phase of Inspire Health. Ms. Herron, Ms. Anderson, Ms. Cornell, Mr. DeLester, Ms. Purvis, Mr. Minnis, Ms. McGill, Mr. Manfredo, Dr. Boyd, Dr. Bond, Mr. Hopkins, Mr. Harden, Ms. Martin, Ms. Todd left the meeting at 6:35pm. Agenda Item XIII. Proposed Executive Session A. Proposed Vote to Convene an Executive Session Pursuant to 25 Okla. Stat. Section 307 B.4. to Discuss with Legal Counsel Pending Internal Peer Review/Credentialing Investigation Regarding the Medical Staff Members/Applicants Listed Below; and (ii) CEO Evaluation. ACTION TAKEN: Mr. Chappel made a motion to adjourn into Executive Session. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Dr. Anwar, Ms. Womack, Mr. Chappel and Ms. Roberts. B. Medical Staff Recommendations Regarding the Medical Staff Members/ Applicants as Listed in XIII.B 1-4 Below. 1. Recommend New Provisional Medical Staff Appointments: a. Dwight Sublett, MD – Pediatrics – Active b. Mary Nixon, MD – OB/GYN – Active c. Yasir Ahmed, MD – Medicine – Consulting NRHA Board Minutes 8 November 28, 2022 d. Stefhanue Gonzales, PA-C – Surgery – Allied Health e. Brenda Lawrie, APRN-CNS – Cardiovascular Medicine – Allied Health f. Amber Fox, APRN-CNP – Pediatrics – Allied Health g. Lisa Pace, RNFA – Surgery – Allied Health h. John Hotchkiss, MD – Radiology – Privileges Only i. Archana Lucchesi, MD – Radiology – Privileges Only j. Jason Burns, DO – Radiology – Privileges Only k. Amy Kirby, MD – Radiology – Privileges Only l. Lincoln Patel, MD – Radiology – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. Abhishek Polavarapu, MD – Medicine – Active b. Kara Hatlevoll, DO – Nocturnist/Procedure Team – Hospital Medicine – Privileges Only 3. Recommended Medical Staff Reappointments: a. Mudassir Nawaz, MD – Medicine 0 Active b. Lesa Mulligan, MD – OB/GYN – Active c. Gautam Dehadrai, MD – Radiology – Active d. Graham Roberts, MD – Radiology – Active e. Wayne Berryhill, MD – Surgery – Active f. Alexander Jones, MD – Surgery – Active g. Jeff Raines, DO – Emergency Medicine – Active h. Brant Bennett, MD – Medicine – Active i. Shari Jones, MD – Medicine – Active j. Steven Schultz, MD – Surgery – Active k. Vytautas Ringus, MD – Surgery – Active l. Shane Stidham, MD – Anesthesia – Active m. Carrie Barton, MD – Emergency Medicine – Active n. Daniel Kite, DO – Emergency Medicine – Active o. M. Edmund Braly, MD – Emergency Medicine – Consulting p. Darren Dupus, APRN-CRNA – Anesthesia – Allied Health q. Lara Green, PA-C – Surgery – Allied Health r. Darren Gose, APRN-CRNA – Anesthesia – Allied Health s. Glenroy Hines, PA-C – Surgery – Allied Health t. Steven Braudway, APRN-CNP – Emergency Medicine – Allied Health u. Jeffrey Bivens, PA-C – Medicine – Allied Health v. Brooke Burks, APRN-CNP – Pediatrics – Allied Health w. Karen Tyndall, PhD – Medicine – Allied Health 4. Information Only a. Hannah Elliott, PA-C has completed proctored cases for Solid Organ Biopsy and Lung Biopsy b. Nathan White, PA-C has completed proctored cases for Percutaneous Nephrostomy Tube c. Michael Martin, MD requests Vertebroplasty/Kyphoplasty privileges d. Mark Sauerwald, DO requests privileges for Endotracheal Intubation  NRHA Board Minutes 9 November 28, 2022 and Emergency Medicine Moonlighting e. Elizabeth Richardson, DO requests privileges for Emergency Medicine Moonlighting Dr. Voto and Mr. Splitt left the meeting at 6:40pm C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session ACTION TAKEN: Mr. Chappel made a motion to adjourn out of Executive Session. Ms. Womack seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Dr. Anwar, Ms. Womack, Mr. Chappel and Ms. Roberts. Mr. Cubberley noted the Board returned to regular session. There were no decisions or votes taken except to return to regular session and any information shared during the Executive Session is privileged and needs to remain in Executive Session. D. Proposed Vote to Approve or Disapprove the Medical Executive Committee Recommendations Regarding Credentialing of the Referenced Medical Staff Members as Listed in XII B 1-4 ACTION TAKEN: Mr. Chappel motioned to approve credentialing items as recommended by Medical Executive Committee and Credentials Committee of all referenced Medical Staff members listed in XII B 1-4. Ms. Womack seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Dr. Anwar, Ms. Womack, Mr. Chappel and Ms. Roberts. E. Proposed Vote to Approve or Disapprove the CEO Evaluation ACTION TAKEN: Mr. Chappel motioned to approve the CEO Evaluation. Ms. Womack seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Dr. Anwar, Ms. Womack, Mr. Chappel and Ms. Roberts. Mr. Splitt returned to the meeting following the Executive Session at 8:41pm. Agenda Item XIV. Board Open Discussion The Board provided feedback to Mr. Splitt regarding the CEO Evaluation. Agenda Item XV. Adjournment ACTION TAKEN: Dr. Anwar made a motion to adjourn the meeting at 9:15pm. Ms. Roberts seconded, and the motion passed unanimously with aye votes  NRHA Board Minutes 10 November 28, 2022 from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Dr. Anwar, Ms. Womack, Mr. Chappel and Ms. Roberts. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary